Pregnancy outcomes in an international cohort of autoimmune hepatitis.

BACKGROUND & AIMS: Autoimmune hepatitis (AIH) poses challenges in pregnancy, including immunosuppression (IMS) management and risks of adverse pregnancy outcomes. Granular AIH pregnancy data are limited.

METHODS

This two-center retrospective study included pregnancies in women with AIH at King's College Hospital and the University of California, San Francisco between 1970 and 2024. Clinical characteristics, IMS regimens and pregnancy outcomes were obtained from chart review. Liver biochemical markers and prognostic scores were assessed as predictive tools for pregnancy outcomes.

RESULTS

There were 197 AIH pregnancies in 112 women. AIH pregnancies increased over time (p <0.001). Median age at conception was 29 years. Cirrhosis was present in 43% of pregnancies. IMS was used in 84% of pregnancies. Preconception counseling was provided in 52% of pregnancies and was associated with higher IMS use (61% vs. 31%, p = 0.008). Live birth occurred in 88% of pregnancies, with preterm delivery in 24%. Gestational complications included intrahepatic cholestasis of pregnancy (9%) and preeclampsia (8%). Preterm birth was more common in pregnancies complicated by cirrhosis (33% vs. 16%, p = 0.04), although live birth rates were similar. Loss of biochemical response occurred more frequently postpartum than during pregnancy (25% vs. 6%, p <0.001). The UKELD score was the strongest predictor of live birth (AUROC 0.75), followed by MELD-Na (AUROC 0.73), while preconception AST <33 IU/L predicted maintenance of biochemical response (AUROC 0.65).

CONCLUSIONS

AIH in pregnancy carries meaningful risks, including a 9% risk of intrahepatic cholestasis and increased preterm birth in women with cirrhosis. Preconception counseling and immunosuppression adherence are associated with favorable outcomes. Preconception UKELD and AST levels may guide individualized risk stratification for live birth and biochemical response.

IMPACT AND IMPLICATIONS: This large two-center study provides one of the most comprehensive characterizations of autoimmune hepatitis (AIH) in pregnancy, demonstrating high live birth rates but clinically meaningful risks, particularly in women with cirrhosis. It highlights intrahepatic cholestasis of pregnancy and preterm delivery as key complications and shows that disease control and immunosuppression adherence are associated with improved outcomes. Importantly, the study identifies preconception counseling as a modifiable factor linked to better treatment continuation, and introduces UKELD and AST as potential tools for pre-pregnancy risk stratification. These findings support structured preconception care and suggest that validated liver disease scores may help individualise counseling and management in women with AIH considering pregnancy.